The Nurse Auditor, using a unique combination of clinical expertise and regulatory compliance knowledge, monitors and improves the quality of clinical documentation and regulatory standards adherence related to the Medically Dependent Childrens Program (MDCP) and regulatory requirements for the Appeals and Grievances (MDCP/Appeals) processes. The Nurse Auditor is a subject matter expert for process adherence involved in the care of MDCP members and ensuring the documentation accuracy of compliance with regulatory requirements for the program. The Nurse Auditor is a subject matter expert for the Appeals and Grievances processes ensuring all required processes and documentation details are adhered to and compliant with regulatory requirements. This position participates in retrospective audits where warranted. The Nurse Auditor will be responsible for tracking and trending of audit outcomes in addition to tracking and reporting year-over-year trends of audit standards. This position will work collaboratively with interdisciplinary leadership and staff to identify opportunities for process improvement leading to increased compliance with standards and requirements. This position works independently and in an unbiased approach to all audit practices and outcomes.
EDUCATION/EXPERIENCE
Bachelors degree in nursing is required. Masters degree in nursing is highly preferred. Three years of nursing experience is required (staff nurse II or above). Work experience in audits, utilization review, or quality assurance is preferred. Knowledge of the criteria for Medicare, Medicaid, HMO, and private insurance coverage is highly preferred.
LICENSURE
Current licensure as a Registered Nurse with the Texas State Board of Nurse Examiners is required.
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